Pain in Asia: the influence of language and culture
14 Jul 2015 | Print
The management of pain requires more than medical knowledge: it requires levels of human understanding that go beyond conventional ideas of bedside manner.
In particular, to understand their patients, pain physicians need high levels of ‘cultural competence’ – in other words, sensitivity to the influence of culture (nationality, ethnicity, religion, etc.) on perceptions of pain and illness. They also need high levels of ‘linguistic competence’, not just with regard to the nuances of verbal language expressed by patients who are in pain, but also their non-verbal (body) language.
At first, this might appear straightforward. Human beings instinctively understand a child’s cries of pain, and most languages have easily understood words similar to the English “ow” with which to express pain.
However, more sophisticated layers of language and culture add complexity on top of these universal declarations of pain.
Language and pain
Some cultures place pain so centrally to their idea of being unwell that the two concepts have been combined. For example, in Malay, Indonesian and Filipino, the word “sakit” means both “pain” and “illness”.
Language is also very important in helping patient to describe their pain. Indeed, most of the languages of Asia – whether of local or European origin – offer multiple ways to describe pain. These may include descriptions of the location (eg, headache, backache), type (eg, sharp, throbbing, dull), character (eg, intermittent, continuous) and intensity (eg, mild, moderate, severe) of pain.
Furthermore, a patient’s culture can sometimes be crucial in defining the metaphors they use to describe pain. For example, the Sakhalin Ainu people of Japan differentiate headaches as “bear headaches” that feel like the heavy steps of bears; “deer headaches” that feel like the lighter sounds of running deer; and “woodpecker headaches” that feel like a woodpecker tapping a tree.
Culture and pain
Culture can have multiple influences on the experience of pain.
For example, cultures differ greatly in their ‘authorization’ of pain – the degree to which overt expression of pain is acceptable in daily life. In a comparison of college students in the USA and India given a cold pressor test, those in India were less accepting of overt pain expression than their USA counterparts. In the same study, females believed that overt pain expression was more appropriate than did males. This gender difference may be common to many cultures.
The simple conclusion to draw from this is that the level of pain a patient is expressing may not be a good indicator of how much pain they are actually experiencing.
Some cultures also bring an existential element to pain – in other words, a sense that pain is a normal and non-negotiable part of life. Indeed, many languages incorporate the concept of enduring pain in a stoical fashion. For example, the Chinese has the term “chi ku”, which translates as “eating bitterness” or “enduring pain”.
This idea can manifest itself in many different ways. One example is a view among some patients (and physicians) that society as overmedicated, and hence that the use of pharmacological pain treatments should sometimes be resisted. This could offer at least a partial explanation for the continued underuse of opioids in Asia, for example, in the Philippines.
Faith can also play a significant role in the experience of pain. Some of the world’s most widely practiced religions view pain as a form of punishment, and also as potential redemption – for example, the Holy Week self-flagellation rituals among Filipino Catholics or the body piercing associated with Thaipusam among Malaysian Hindus.[8,9]
As pain physicians, we need to be sensitive to the possibility that some patients may consider pain as a spiritual, as well as a physiological experience. This can have particularly important implications for adherence, because patients who place themselves at the mercy of divine intervention may be less likely to adhere to medication.
On the flipside, faith can provide a structure to life that may improve adherence. Indeed, work in Thailand showed that patients with strong Buddhist values were more adherent to medication and lifestyle changes (albeit in the context of diabetes rather than pain).
Culture can also offer opportunities to alleviate pain. The obvious example is traditional medicines, like those from China and Korea, which have proven efficacy in improving pain.[12,13] However, more ritualistic elements that take the mind away from pain – such as comfort foods – are also worthy of exploration.
Conclusions – key challenges
It is clear that both language and culture play a key role in our understanding, experience and communication of pain. From a research perspective, the key challenge will be to collect more data on these links, particularly within the Asian context. Meanwhile, from a clinical perspective, pain physicians should continue to acquire the skills of linguistic and cultural competence, so that they can better respond to the subtle differences in their patients’ experience of pain.
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